Saturday, April 11, 2009

Lit Bits: April 11, 2009

From the recent medical literature...

1. Mag Sulfate for A Fib: Is it Worth the Bother?

Magnesium Sulfate versus Placebo for Paroxysmal Atrial Fibrillation: A Randomized Clinical Trial

Chu K, et al. Acad Emerg Med 2009;16:295-300.

Objectives: The objective was to investigate the efficacy of magnesium sulfate (MgSO4) in decreasing the ventricular rate in emergency department (ED) patients presenting with new-onset, rapid atrial fibrillation (AF).

Methods: A double-blinded, placebo-controlled randomized clinical trial was conducted in an adult university hospital. Patients aged ≥18 years with AF onset of less than 48 hours and a sustained ventricular rate of more than 100 beats/min were randomized to either intravenous (IV) MgSO4 10 mmol or normal saline (NSal). Rhythm and instantaneous heart rate as measured by the monitor were recorded at baseline and every 15 minutes for 2 hours after starting the trial drug. Heart rate and rhythm were compared at 2 hours. A multilevel modeling analysis was performed to adjust for differences in baseline heart rate and any additional treatment and to examine changes in heart rate over time.

Results: Twenty-four patients were randomized to MgSO4 and 24 to NSal. Baseline heart rate was lower in the MgSO4 group (mean ± standard deviation [±SD] = 125 ± 24 vs. 140 ± 21 beats/min]. One and 3 patients in the MgSO4 and NSal groups, respectively, were given another antiarrhythmic or were electrically cardioverted within 2 hours after starting the trial drug. Heart rate (mean ± SD) at 2 hours in both MgSO4 (116 ± 30 beats/min) and NSal groups (114 ± 31 beats/min) decreased below their respective baseline levels. However, the rate of heart rate decrease across time did not differ between groups (p = 0.124). The proportion of patients who converted to sinus rhythm 2 hours post–trial drug did not differ (MgSO4 8.7% vs. NSal 25.0%, p = 0.25).

Conclusions: This study was unable to demonstrate a difference between IV MgSO4 10 mmol and saline placebo for reducing heart rate or conversion to sinus rhythm at 2 hours posttreatment in ED patients with AF of less than 48 hours duration.

2. Diagnosing Appendicitis: Ultrasound First?

A diagnostic pathway using ultrasound as the primary study, followed by CT for patients with negative or inconclusive ultrasound findings, had high accuracy for diagnosing appendicitis.

Poortman P, et al. J Amer Coll Surg 2009;208:434-441

Preoperative imaging has been demonstrated to improve diagnostic accuracy in appendicitis. This prospective study assessed the accuracy of a diagnostic pathway in acute appendicitis using ultrasonography (US) and complementary contrast-enhanced multidetector CT in a general community teaching hospital.

Study Design
One hundred fifty-one patients with clinically suspected appendicitis followed the designed protocol: patients underwent operations after a primary performed positive US (graded compression technique) or after complementary CT (contrast-enhanced multidetector CT) when US was negative or inconclusive. Patients with positive CT findings underwent operations. When CT was negative for appendicitis, they were admitted for observation. Results of US and CT were correlated with surgical findings, histopathology, and followup.

Positive US was confirmed at operation in 71 of 79 patients and positive CT was confirmed in all 21 patients. All 39 patients with negative CT findings recovered without operations. The negative appendicitis rate was 8% and perforation rate was 9%. The sensitivity and specificity of US was 77% and 86%, respectively. The sensitivity and specificity of CT was both 100%. The sensitivity and specificity of the whole diagnostic pathway was 100% and 86%, respectively.

A diagnostic pathway using primary graded compression US and complementary multidetector CT in a general community teaching hospital yields a high diagnostic accuracy for acute appendicitis without adverse events from delay in treatment. Although US is less accurate than CT, it can be used as a primary imaging modality, avoiding the disadvantages of CT. For those patients with negative US and CT findings, observation is safe.

3. Just Medicine

By Philip K. Howard, The New York Times, April 2, 2009

WASTE in the health care system costs America upwards of $1 trillion per year. Much of this waste is generated or justified by the fear of legal consequences that infects almost every health care encounter. The good news is that it would be relatively easy to create a new system of reliable justice, one that could support broader reforms to contain costs.

The legal system terrorizes doctors. Fear of possible claims leads medical professionals to squander billions in unnecessary tests and procedures. “Defensive medicine” is so prevalent that it has become part of standard protocol — for example, mandatory pre-operative exams even where the patient record is current, and even for minor procedures.

Like a cancer, this legal anxiety corrodes relationships with patients. Doctors and nurses don’t want to speak up for fear of assuming legal liability, and this causes unnecessary errors. Under instructions from lawyers, they don’t apologize or offer explanations when things go wrong. They sometimes conceal errors in an effort to avoid a legal ordeal.. Even in ordinary daily encounters, an invisible wall separates doctors from their patients. As one pediatrician told me, “You wouldn’t want to say something off the cuff that might be used against you..”

As the culture of health care disintegrates, costs rise further. In hospitals, self-protective bureaucracy multiplies. Patient encounters require witnesses, wasting professional time. Patients, sensing distrust, demand second opinions even on minor ailments. There are psychological costs as well: doctors no longer find professional fulfillment and drop out in their prime. Forget productivity — sometimes doctors avoid using e-mail so they don’t have to put things in writing.
Restoring a foundation of trust requires a new system of medical justice. Medical cases are now decided jury by jury, without consistent application of medical standards. According to a 2006 study in the New England Journal of Medicine, around 25 percent of cases where there was no identifiable error resulted in malpractice payments. Nor is the system effective for injured patients — according to the same study, 54 cents of every dollar paid in malpractice cases goes to administrative expenses like lawyers, experts and courts.

America needs special health courts aimed not at stopping lawsuits but at delivering fair and reliable decisions. A special court would provide expedited proceedings with knowledgeable staff that would work to settle claims quickly. Trials would be conducted before a judge who is advised by a neutral expert, with written rulings on standards of care.

With a special health court, damages would consist of all lost income and medical costs, plus “pain and suffering” based on a set schedule depending on the severity of the injury. All information about each incident, including details learned in settlements, would be compiled and disseminated so that doctors and hospitals could learn from their errors. Proponents of special health courts have estimated that the total cost of such a new liability system would be about the same as the existing system — less than 2 percent of America’s total health care costs. One benefit would be that the quicker, streamlined system would compensate far more people, with drastically lower legal costs. Most important, it would restore faith in the reliability of medical justice.

A court that freed doctors from worries about unnecessary and unreasonable malpractice claims would transform the culture of health care. Doctors could finally emerge from their defensive cocoons and start focusing on the health of the patient. Hospitals would concentrate on productivity and safety. Doctors could be more candid about decisions for terminally ill patients, and offer more guidance about high-risk procedures.

This country has a long tradition of courts and tribunals to deal with issues like bankruptcy that require special expertise. Nowhere is that expertise, along with the stability and trust it would bring, more needed than in health care.

Several prominent hospitals, including New York Presbyterian, have said they are interested in being part of a health court pilot project. Some large consumer and patient safety groups support the idea. The fastest way to do this would be for Congress to authorize and finance pilot courts around the country. These ideas already have some bipartisan support: Bills for alternative medical justice systems have been introduced in Congress.

Cutting back on the notorious inefficiency of American health care is essential to achieve universal care, as well as make the American economy more competitive. Part of the solution — overhauling the reimbursement model so that doctors get paid only for what is needed — is unavoidably complex. But restoring trust in law, the other essential reform, can be accomplished with the creation of reliable courts.

Philip K. Howard, a lawyer, is the chairman of Common Good, a legal reform coalition, and the author of “Life Without Lawyers: Liberating Americans From Too Much Law.”

4. Ottawa Ankle Rules in Kids Five and Up: They Work

Dowling S, et al. Acad Emerg Med. 2009;16:277-287.

Objectives: The objectives were to conduct a systematic review to determine the diagnostic accuracy of the Ottawa Ankle Rules (OAR) to exclude ankle and midfoot fractures in children and the extent to which x-ray use could be reduced without missing significant fractures.

Methods: The authors conducted comprehensive searches of electronic databases and gray literature sources. Independent reviewers applied standard inclusion and exclusion criteria. The criterion standard diagnostic test was an ankle and/or foot x-ray or proxy measure to ensure no missed fractures. Standard 2 × 2 tables were constructed. Sensitivities and specificities were pooled using an approximation of the inverse variance; 95% confidence intervals (95% CIs) were calculated using the exact method. Likelihood ratios (LR ±) and diagnostic odds ratios were combined under DerSimonian and Laird random effects model.

Results: A pooled analysis of 12 studies (N = 3,130) identified 671 fractures (prevalence = 21.4%). Ten studies reported Salter-Harris Type I (SH-I) fractures. The pooled sensitivity was 98.5% (95% CI = 97.3 to 99.2), suggesting that the OAR can be used to rule out a fracture. Four of 10 missed fractures were characterized: 1 SH-I, 1 SH-IV, and 2 "insignificant fractures" (either SH-I or avulsion fractures less than 3 mm). The pooled estimate for rate of x-ray reduction was 24.8% (95% CI = 23.3% to 26.3%; range = 5% to 44%).

Conclusions: The OAR appear to be a reliable tool to exclude fractures in children greater than 5 years of age presenting with ankle and midfoot injuries. Employing the OAR would significantly decrease x-ray use with a low likelihood of missing a fracture.

5. It’s Time to Make a Coffee Run: The Athletic Advantages of Caffeine

By GINA KOLATA. NY Times. March 25, 2009

WELDON JOHNSON first tried caffeine as a performance enhancer in 1998. He was not a coffee drinker but had heard that caffeine could make him run faster. So he went to a convenience store before a race and drank a cup of coffee.

For the first time in his life, he ran 10 kilometers in less than 30 minutes.

“I remember being really wired before the race,” he said in an e-mail message. “My body was shaking.”

From then on, he was a convert.

Mr. Johnson, a founder of, would avoid caffeine, even in soft drinks, for a few weeks before he competed in a race, wanting to have the full stimulant effect.

“It may have been a huge placebo effect, but I swore by it,” Mr. Johnson said. “Having a cup of coffee exactly one hour before the race was part of my routine.”

Or maybe it was not a placebo effect.

Caffeine, it turns out, actually works. And it is legal, one of the few performance enhancers that is not banned by the World Anti-Doping Agency.


6. Rota and Pneumococcus Vaccine Success Stories: Pediatric Emergency Practitioners Wonder “Where Have the Kids Gone?”

McKenna M. Ann Emerg Med. 2009;53:A23-A25

Across US emergency departments (EDs) this past winter, there was the usual range of childhood illnesses: fever, falls, flu. But to the enormous relief of pediatric emergency practitioners, 2 sets of symptom complexes made an appearance much less often: the severe gastroenteritis caused by rotavirus infection, and the pneumonia, bacteremia and meningitis of invasive S. pneumoniae disease.

The near disappearance of rotavirus gastroenteritis and invasive pneumococcal disease is a real-world demonstration of the efficacy of vaccine, in this case Prevnar and Rotateq. Neither vaccine is brand-new: Prevnar was released in the United States in 2000, and Rotateq in 2006.

Yet this winter in particular, emergency physicians seemed to find the vaccines' impact particularly striking, noticing the cases they were no longer seeing and reflecting on the changes the vaccines have brought to their working lives.

“Without question, Prevnar and the rotavirus vaccine have remarkably changed our practice,” said Stuart Bradin, DO, assistant professor of pediatrics and emergency medicine at the University of Michigan Health System, Ann Arbor, MI. “The workups we do now on patients are much less invasive, at least for a well-appearing child.”

Marianne Gausche-Hill, MD, Director, Emergency Medical Services at Harbor-UCLA Medical Center, Los Angeles, CA, who practices in both the pediatric and the adult EDs, added: “We've all been asking ourselves, Where have the kids gone?”

The declines in incidence are so noticeable because the impact of those diseases was so recently so dire. Before the introduction of Prevnar, a 7-serotype conjugate vaccine made by Wyeth Lederle Vaccines, invasive pneumococcal disease occurred in 24 out of every 100,000 US children younger than 5. In the first year the vaccine was released—a year in which demand was so strong that there was a shortage—bacteremia and meningitis caused by the targeted serotypes fell by 29% in children under 5. Among children younger than 2, it sank 69%.1

By 2004, the vaccine was also shown to reduce hospitalizations of young children by 39%2 and outpatient visits by 41%.3 It cut pneumococcal otitis media by 34%4 and significantly reduced nasal carriage of both drug-sensitive and antibiotic-resistant S. pneumo.5 And it created herd immunity as well, preventing pneumococcal disease among unvaccinated younger children6 and among adults.1

The need for a rotavirus vaccine was just as great: Before Rotateq's introduction, rotavirus caused few deaths in the US—between 20 and 60 in any year, according to the Centers for Disease Control and Prevention (CDC)—but enormous amounts of illness: from 55,000 to 70,000 hospitalizations, 272,000 ED visits and 410,000 outpatient or office visits.7, 8 But the road to a vaccine was bumpy. A tetravalent rhesus reassortant vaccine called RotaShield, also made by Wyeth, was introduced in 1998 after trials demonstrated efficacy of up to 83% against all rotavirus gastroenteritis, and up to 95% against severe disease.9 However, the vaccine was withdrawn the next year after 15 infants experienced intussusception and 8 required surgery.10

A Second Chance
It took 7 years before a substitute vaccine—Rotateq, a pentavalent human-bovine reassortant made by Merck—was introduced…

The rest of the article (free!):

7. Whole-Body CT May Improve Survival for Patients With Polytrauma

March 27, 2009 — For patients with polytrauma, integrating whole-body computed tomography (CT) scan into early trauma care significantly increases the probability of survival, according to the results of a retrospective, multicenter study reported in the March 24 Online First issue of The Lancet.

"The number of trauma centres using whole-body CT for early assessment of primary trauma is increasing," write Stefan Huber-Wagner, from Munich University Hospital in Munich, Germany, and colleagues from the Working Group on Polytrauma of the German Trauma Society. "There is no evidence to suggest that use of whole-body CT has any effect on the outcome of patients with major trauma. We therefore compared the probability of survival in patients with blunt trauma who had whole-body CT during resuscitation with those who had not."

The investigators used the data recorded in the trauma registry of the German Trauma Society to determine survival outcomes for 4621 patients with blunt trauma who received whole-body or non–whole-body CT. Survival probability was calculated according to the trauma and injury severity score (TRISS), revised injury severity classification (RISC) score, and standardized mortality ratio (SMR, ratio of recorded to expected mortality).

Of the 4621 patients, 1494 (32%) underwent whole-body CT. Of these patients, 3364 (73%) were men. Mean age was 42.6 ± 20.7 years, and mean injury-severity score was 29.7 ± 13·0. Based on TRISS, SMR was 0.745 (95% confidence interval [CI], 0.633 - 0.859) for patients who underwent whole-body CT vs 1.023 (95% CI, 0.909 - 1.137) for those who underwent non–whole-body CT (P less than .001).

Based on the RISC score, SMR was 0.865 for patients who underwent whole-body CT vs 1.034 for those who underwent non–whole-body CT (P = .017). Relative risk reduction (RRR) in mortality rate based on TRISS was 25% vs 13% based on RISC score. Whole-body CT was an independent predictor for survival (P less than .002), even after multivariate adjustment for hospital level, year of trauma, and potential center effects. To prevent 1 death, the number needed to scan was 17 based on TRISS and 32 based on RISC calculation.

"Integration of whole-body CT into early trauma care significantly increased the probability of survival in patients with polytrauma," the study authors write. "Whole-body CT is recommended as a standard diagnostic method during the early resuscitation phase for patients with polytrauma."

Limitations of this study include retrospective design; missing data in the trauma registry, allowing calculations of TRISS in only 49% and RISC score in 89% of patients; clear protocol for or against whole-body CT not clearly defined; lack of data about structural differences of the participating hospitals, such as the location of the CT scanner and transportation times between the trauma room and CT suite; lack of data about CT protocols or implementation of the principles of advanced trauma life support; potentially different intercenter consistency in grading injuries; and possible residual confounding.

"Despite these limitations, our results indicate that the probability of survival for patients with major trauma can be significantly increased by use of whole-body CT," the study authors conclude. "On the basis of our findings, we recommend that whole-body CT should be integrated into the early resuscitation phase of severely injured patients as a standard and basic diagnostic method."

The trauma registry of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie) was partly funded by the Deutsche Forschungsgemeinschaft Ne 385/5 and Novo Nordisk A/S, supported this study. The study authors have disclosed no relevant financial disclosures.

Lancet. Published online March 24, 2009. Reviewed by Laurie Barclay, MD

8. Pretreatment of Patients Requiring Oral Contrast Abdominal CT With Antiemetics: A Randomized Controlled Trial of Efficacy

Garra G, et al. Ann Emerg Med. 2009;53:528-533.

Study objective
Ingestion of diatrizoate meglumine before abdominal computed tomography (CT) is time consuming. We hypothesized that pretreatment with metoclopramide or ondansetron would result in faster ingestion of diatrizoate meglumine than placebo.

The study was a double-blind, randomized controlled trial on adults requiring oral contrast abdominal CT. Patients were randomized to placebo, metoclopramide 10 mg, or ondansetron 4 mg intravenously 15 minutes before ingesting 2 L of diatrizoate meglumine. The primary outcome was time to complete diatrizoate meglumine ingestion. Secondary outcome measures included volume of diatrizoate meglumine ingested, 100-mm visual analog scale for nausea at 15-minute intervals, time to CT, vomiting, and use of rescue antiemetics. The study was powered to detect a 60-minute difference in diatrizoate meglumine ingestion time between saline and medication groups.

One hundred six patients were randomized; placebo (36), metoclopramide (35), and ondansetron (35). Groups were similar in baseline characteristics. Median (interquartile range) times for diatrizoate meglumine ingestion were placebo 109 minutes (82 to 135 minutes); metoclopramide 105 minutes (75 to 135 minutes); and ondansetron 110 minutes (79 to 140 minutes) (P=.67). Vomiting was less frequent with metoclopramide (3%) than placebo (18%) or ondansetron (9%) (P=.11). The visual analog scale for nausea at each point was not significantly different between groups (P=.11). The need for rescue antiemetics was lowest for metoclopramide (3%) compared with placebo (27%) and ondansetron (12%) (P=.02).

Pretreatment with ondansetron or metoclopramide does not reduce oral contrast solution ingestion time.

9. CT for Ovarian Torsion

In a review of 28 cases of surgically proven ovarian torsion, preoperative CT scans detected an ovarian abnormality in all patients.

Moore C, et al. J Emerg Radiology 2009;16:115-120.

Many women with ovarian torsion present with nonspecific abdominal/pelvic pain and initially receive computed tomography (CT). We hypothesize that the CT scans preformed on these women will all show abnormalities of the involved ovary. Our purpose is to review cases of surgically proven ovarian torsion at our institution over the last 20 years, assessing CT findings in women with ovarian torsion.

A retrospective review of all patients at our institution with surgically proven ovarian torsion from 1985–2005 was conducted. Two physicians reviewed available CT reports, and a radiologist reviewed all available images. CT was obtained in 33% of the 167 patients. Dictated reports were available for 28 studies; all described an enlarged ovary, ovarian cyst, or adnexal mass of the involved ovary. Radiologist review of the available CT images confirmed these findings.

This series supports the claim that a CT scan with well-visualized normal appearing ovaries rules out ovarian torsion, while abnormal pelvic findings or failure to visualize the ovaries in women with pelvic pain necessitates further evaluation of torsion.

10. Clinical Assessment of the Crying Infant Should Guide Decision Making

Laurie Barclay, MD. March 25, 2009 — History and physical examination is the key to evaluate the crying infant and to determine testing, which should include urine evaluation for afebrile infants in the first few months of life, according to the results of a retrospective review reported in the March issue of Pediatrics.

"Although the differential diagnosis of crying is extensive, the frequency of severe underlying disease is unclear," write Stephen B. Freedman, MDCM, MSc, FRCPC, from Hospital for Sick Children, University of Toronto in Toronto, Ontario, Canada. "On the basis of very limited data, it has been recommended that corneal fluorescein staining, eyelid eversion, and rectal examination be performed on crying infants."

The goal of this study was to assess the proportion of children who have a serious underlying cause for crying evaluated in an emergency department. Secondary objectives were to examine the individual contributions of history, physical examination, and laboratory testing in reaching a diagnosis.

Records were reviewed for all afebrile patients younger than 1 year presenting to the emergency department with a chief complaint of crying, irritability, screaming, colic, or fussiness. Criteria defined a priori were used to identify all children with a serious underlying disease. To evaluate whether history, physical examination, or testing contributed to establishing the diagnosis, the investigators performed a chart review.

There were 237 patients, representing 0.6% of all visits, who met enrollment criteria. Serious underlying causes were present in 12 children (5.1%). Urinary tract infection was the most frequent of these causes, present in 3 children, and 2 (16.7%) of the serious diagnoses were reached only when the child was reevaluated.

Although the results of 81 (14.1%) of 574 tests performed were positive, only 8 diagnoses (1.4%) were reached because of a positive test result. In contrast, two thirds (66.3%) of cases were diagnosed in part because of suggestive findings on history and/or physical examination. Unwell appearance was noted in many infants that turned out to have various serious underlying conditions.

Gastroesophageal reflux disease was diagnosed based on clinical presentation in 13% of infants. This did not vary significantly by age.

In the absence of a suggestive clinical picture, testing contributed to the diagnosis in only 2 children (0.8%), both of whom were younger than 4 months and had urinary tract infections. The positive rate of urine culture results was 10% in children younger than 1 month. Ocular fluorescein staining and rectal examination with occult blood testing were rarely performed, and all results were negative. No missed diagnoses were found at follow-up, which was completed with 60% of caregivers.

"History and physical examination remains the cornerstone of the evaluation of the crying infant and should drive investigation selection," the study authors write. "Afebrile infants in the first few months of life should undergo urine evaluation. Other investigations should be performed on the basis of clinical findings."

Specific features of history and physical examination thought to be suggestive of specific conditions were as follows:

• Atypical colic: Colic diagnosed by the treating clinician but not meeting the definition of colic as described in the fourth bulleted item.

• Bacterial meningitis: Fever, paroxysmal irritability, lethargy, vomiting, full or bulging fontanelle, meningismus, positive results on cerebrospinal fluid culture.

• Bronchiolitis: Cough, fever, wheezing, rapid respirations, apnea, poor feeding, positive testing result for respiratory syncytial virus, evidence of bronchiolitis on imaging.

• Colic: Paroxysmal crying more than 3 hours per day, more than 3 days per week, lasting more than 3 weeks in an otherwise healthy child older than 3 weeks but younger than 4 months.

• Constipation: History of infrequent, hard stools that are difficult to pass, and palpation of small pellets on abdominal examination.

• Cow's milk allergy: Alleviation of symptoms when cow's milk is removed from the diet.

• Crying: No alternative findings that explain the episode.

• Gastroesophageal reflux: Visible regurgitation, refusal of feedings, Sandifer's syndrome.

• Hernia: History or physical examination revealing a bulge in the groin or umbilicus.

• Intussusception: Sudden onset of severe, intermittent abdominal pain; drawing up legs; well-appearing between episodes; vomiting, lethargy, bright red or occult blood in stool; "currant jelly" stools, sausage-shaped abdominal mass, imaging consistent with intussusception.

• Otitis media: Fever, ear discharge, pulling or rubbing the ear. Tympanic membrane findings include erythema, bulging, loss of landmarks, effusion, and/or reduced mobility.

• Pneumonia: Cough, fever, tachypnea, poor feeding, recent upper respiratory tract infection, leukocytosis (greater than 20 x 109 white blood cells/L), focal findings on auscultation, imaging findings consistent with pneumonia.

• Urinary tract infection: Fever, malodorous urine, dysuria, frequency, vomiting, result of urinalysis positive for leukocyte esterase and/or nitrites; culture of catheter specimen result positive for at least 50,000 CFU/mL.

• Viral illness (herpangina, influenza, nasal congestion, roseola, upper respiratory tract infection, viral exanthem, or viral meningitis): Fever, cough, runny nose, nasal congestion, sneezing, vomiting, diarrhea, skin rash, contact with an ill person.

Limitations of this study include retrospective chart review, reducing accuracy and completeness of the abstracted data; absence of a uniform testing protocol, with tests performed on the basis of individual clinician clinical judgment; inability to make firm conclusions regarding the usefulness of tests that were infrequently performed; the possibility that patients who were discharged with a diagnosis of colic, atypical colic, or crying may have included some patients with serious undetected pathologic conditions; and lack of guarantee of causality from the presence of a diagnosed condition in individual cases.

"The etiology of crying ranges from benign to life-threatening," the study authors conclude. "A selective workup guided by clinical findings seems to be optimal....Other investigations such as rectal examination and fluorescein staining should be performed on the basis of the findings from the history and physical examination."

The study authors have disclosed no relevant financial relationships.

Pediatrics. 2009;123:841-848.

11. Which ED COPDers are Most Likely to Need Admission?

Rowe BH, et al. Acad Emerg Med 2009;16:316-324.

Objectives: The objective was to examine predictors of hospital admission among adults presenting to Canadian emergency departments (EDs) for acute exacerbations of chronic obstructive pulmonary disease (COPD). Current acute treatment approaches and outcomes 2 weeks after the ED visit are also described.

Methods: Subjects, aged 35 years or older presenting with COPD exacerbations to 16 EDs across Canada, underwent a structured in-ED interview and a telephone interview 2 weeks later.

Results: Of 501 study patients, 247 (49.3%) were admitted. Admitted patients were older, were more often former smokers, and had more admissions for COPD during the past 2 years. They also reported more days of activity limitation and use of inhaled beta2-agonists in the previous 24 hours. Canadian Triage and Acuity Scale (CTAS), respiratory rate (RR), and airflow obstruction were more severe in the hospitalized group. Most of the patients received inhaled beta2-agonists, anticholinergics, oral corticosteroids (CS), and antibiotics; hospitalized patients received more aggressive treatments. The median ED length of stay (LOS) of admitted patients was 13.1 hours (interquartile range [IQR] = 7.4-23.0) compared to 5.6 hours (IQR = 4.2-8.4) in discharged patients. Admission was associated with at least two COPD admissions in the past 2 years (odds ratio [OR] = 2.10; 95% CI = 1.24 to 3.56), receiving oral CS for COPD (OR = 1.72; 95% CI = 1.08 to 2.74), having a CTAS score of 1–2 (OR = 2.04; 95% CI = 1.33 to 3.12), and receiving adjunct ED treatments (OR = 3.95; 95% CI = 2.45 to 6.35). Use of EDs for usual COPD care was associated with a reduced risk of admission (OR = 0.43; 95% CI = 0.28 to 0.66).

Conclusions: Exacerbations of COPD in Canadian EDs result in prolonged ED stays and approximately 50% hospitalization despite aggressive acute treatment approaches. Historical, severity, and treatment-related factors were strongly associated with hospital admission. Validation of these results should be completed prior to widespread use.

12. ACC 2009: Upper-Limb Ischemia During Ambulance Transfer Reduces Myocardial Perfusion Injury in STEMI

from Heartwire — a professional news service of WebMD

March 28, 2009 (Orlando, Florida) — Inducing upper-limb ischemia in the ambulance during transfer to primary PCI reduces myocardial perfusion injury and infarct size in patients with ST-segment elevation myocardial infarction (STEMI).

Presenting the results of the study during a clinical-trials session of the i2 Summit here at the American College of Cardiology 2009 Scientific Sessions, lead investigator Dr Hans Erik Bøtker (Aarhus University Hospital Skejby, Denmark) said that occluding the brachial artery to induce ischemic conditioning is a simple and safe intervention that has the potential to reduce mortality and morbidity in STEMI patients.

"It is impossible to precondition a patient prior to a heart attack, because you don't know when it's going to come," said Bøtker. "But if you change the timing so that you do the conditioning procedure during an ongoing myocardial ischemia, which means that you're doing it when the patient is having the heart attack, the damage that is caused by the reperfusion when you open the artery is what we're aiming to modify. It seems, from some of our experimental studies, that the reperfusion injury takes place in the first minute after you open the vessel, but we are able to modify it."

Modifying the Reperfusion Injury

In an interview with heartwire, Bøtker explained that the size of the infarct is caused by ischemic damage and reduced by perfusion and the restoration of blood flow. Recent studies, however, have suggested that part of the infarct damage might also be caused by the abrupt reperfusion, and with that in mind, modifying it could limit injury and harness the full benefits reperfusion therapy.

Occluding the brachial artery to induce ischemic preconditioning in coronary stenting was recently shown to reduce myocardial necrosis as a result of the procedure and was also shown to reduce ischemic chest pain and ECG abnormalities during PCI. In this study, however, Bøtker and colleagues sought to induce ischemia prior to the catheterization laboratory.

In total, 108 patients with STEMI underwent conventional PCI while 105 patients underwent ischemic conditioning in the ambulance. In these patients, the paramedic obtained the electrocardiogram, transmitted the data to the hospital, and, when the attending physician confirmed STEMI, had a blood-pressure cuff placed around the patient's upper arm and inflated to 200 mm Hg for five minutes. The conditioning process was repeated four times.

The primary end point, the myocardial salvage index at 30 days, an assessment of the myocardial area at risk, and final infarct size, was available in 70 patients in both treatment arms. Patients treated with ischemic conditioning while en route to the hospital had a significantly higher salvage ratio than those who underwent PCI without remote conditioning. Final infarct size assessed by nuclear scintigraphy was significantly less among those who underwent conditioning. Interestingly, the benefit appeared driven by infarcts caused by left anterior descending (LAD) lesions.

During the clinical-trials session, Dr Roxana Mehran (Columbia University, New York) asked investigators about the primary end point, questioning their choice of myocardial salvage over infarct size, which has been validated in other clinical trials. Bøtker said that investigators chose myocardial salvage as the primary end point because it allowed them, once they had assessed the area at risk, to calculate the index based on the final infarct size. Choosing infarct size as the primary end point would have required a much larger study, somewhere around 500 patients, he said.

Regarding the mechanism of benefit, Bøtker said they do not exactly know how conditioning works, but it's likely that a compound or a series of compounds, as part of a generalized endogenous protective system, is released during ischemia to reduce infarct size.

13. Simple Approach to Preventing Catheter-Related Infections

Chlorhexidine-impregnated sponges cut the infection rate in half.

Catheter-related infections, particularly those associated with central venous catheters (CVCs) in intensive care unit patients, are a major cause of morbidity (80,000 infections annually in the U.S.), mortality (24,000 deaths annually), and cost (US$18,000 per infection). Precautions that significantly lower risk for infection include not using the femoral vein for CVCs, maximal sterile technique, and prompt removal of unnecessary catheters.

French investigators conducted a randomized study of whether chlorhexidine-impregnated sponges would prevent infections in 1636 ICU patients who received either arterial catheters or CVCs (3778 catheter placements). Sponges were placed over the catheter insertion sites at the time of insertion and were replaced with each dressing change; median duration of catheter use was 6 days. The incidence of major catheter-related infections decreased from an already-low baseline level of 1.0% in the control group (19 infections per 1825 catheters) to 0.5% in the sponge group (10 infections per 1953 catheters). The only major adverse event was severe contact dermatitis, which occurred in eight sponge patients.

The researchers also compared 3-day intervals with 7-day intervals for dressing changes (in a 2x2 design). They found no difference in infection rates, but the actual frequency of dressing changes was similar in the groups because of soiled and leaking dressings.

Comment: The main lesson of this study is that a simple intervention can significantly lower the rate of CVC-related infections even when the baseline rate is already low. The absolute risk reduction is small (number needed to treat, 117), but the low cost of these sponges still allows this intervention to be cost-effective.

— Thomas L. Schwenk, MD. Published in Journal Watch General Medicine April 9, 2009. Citation: Timsit J-F et al. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: A randomized controlled trial. JAMA 2009 Mar 25; 301:1231.

14. MRSA Often Found on Stethoscopes of Emergency Medical Personnel

NEW YORK (Reuters Health) Mar 17 - The results of a small study at one tertiary care center suggest that roughly one in three stethoscopes carried by emergency medical service (EMS) professionals harbor methicillin-resistant Staphylococcus aureus (MRSA).

"While stethoscopes are known fomites for MRSA, the prevalence of MRSA in the prehospital setting is not well documented in the literature," Dr. Mark A. Merlin, from Robert Wood Johnson Medical School, New Brunswick, New Jersey, and colleagues write.

The current investigation, reported in the January/March issue of Prehospital Emergency Care, featured a microbiologic analysis of 50 stethoscopes provided by EMS professionals in an emergency department. Test plates that had incubated for 72 hours were then evaluated independently for microbiologic growth by two emergency physicians and one microbiologist. Agreement by all three evaluators was needed for MRSA colonization.

Sixteen stethoscopes had MRSA colonization and 16 subjects could not remember the last time their stethoscope was cleaned. The median time from last stethoscope cleaning to test date was 1 to 7 days. As might be expected, with more recent cleaning, the odds of MRSA colonization fell significantly (p = 0.038).

"In most busy EMS systems, the concept of cleaning an entire ambulance after every patient is not practical," the authors note. "Cleaning a stethoscope, however, is not labor-intensive, does not require much time, and does not require any special equipment beyond currently stocked items."

Prehosp Emerg Care 2009;13:71-74.

15. Images in Emergency Medicine

Man with rash

Man With Right Knee Injury

Adult Female With Head Injury

A Confusing Set of Xrays

16. High Risk Seen With Discharges Against Medical Advice

NEW YORK (Reuters Health) Mar 23 - When patients choose to leave the hospital against medical advice, they put themselves at increased risk for morbidity and mortality, according to a review in the March issue of Mayo Clinic Proceedings.

Dr. David J. Alfandre, from the Department of Veterans Affairs National Center for Ethics in Health Care in New York reviewed studies published since 1970 regarding the prevalence, costs, predictors, and potential interventions for discharges against medical advice. He excluded studies of primary psychiatric admissions and admissions for detoxification or substance abuse.

In one study, investigators found that patients who left against medical advice were 7 times more likely to be readmitted within 15 days compared with patients who were discharged as recommended (21% vs 3%), "almost always for the same diagnosis."

Another investigation among patients with acute MI found that those who left early had a 40% higher risk of death or readmission for MI or unstable angina up to 2 years later.

Based on 30-day readmission data, it has been estimated that readmission due to unsanctioned discharge increases costs by 56%.

Predictors of discharge against medical advice included lower socioeconomic status, male sex, younger age, Medicaid or no insurance, and substance abuse. Among the reasons given, patients often reported personal or family obligations or "feeling better."

One way to prevent patients from leaving against medical advice, Dr. Alfandre suggests, is to address substance abuse problems, through use of protocols to treat alcohol and opioid withdrawal.

He also recommends the use of motivational interviewing, whereby "using nonjudgmental, empathetic questioning, physicians can more fruitfully engage patients in a process designed to uncover the unspoken motivations behind their particular behaviors." This understanding will then permit the physician to better target counseling efforts.

In addition, the author urges clinicians to recognize that "patients often respond to hospitalization with anxiety, depression, and fear, factors that can impair their ability to reason effectively." In some cases, consultation with a psychiatrist may be in order, especially if patients are a risk to themselves or others if they insist on signing out.

Dr. Alfandre emphasizes the need for thorough informed consent, leaving the patient with "full understanding and appreciation of the risks, benefits, and alternatives of the decision." If the patient then makes an informed decision to leave, Dr. Alfandre concludes, the physician should ensure that appropriate follow-up is available.

Mayo Clin Proc 2009;84:255-260.

17. Self-administered Vaginal Swabs Are a Feasible Alternative to Physician-assisted Cervical Swabs for STI Screening in the ED

Berwald N, et al. Acad Emerg Med. 2009;16:360-363.

Background: Screening for sexually transmitted infections (STIs) in the emergency department (ED) is limited by the need for pelvic examination. It has been suggested that using self-administered vaginal swabs (SAVS) for this purpose may save time and resources and may be more comfortable for patients.

Objectives: The objective was to test the feasibility of using SAVS for STI screening in the ED.

Methods: This was a prospective study of female ED patients 18 to 55 years old who consented to physician-assisted cervical swab (PACS) and SAVS in two urban teaching hospitals. The ED personnel offered the test to all patients, whether or not a pelvic examination was indicated, based on their chief complaint. All specimens were analyzed by polymerase chain reaction (PCR) assay. Data are presented as mean ± standard deviation (SD). Categorical data are presented as percentages with 95% confidence intervals (CIs). Patients with a positive test result for Chlamydia trachomatis and/or Neisseria gonorrhoeae were considered positive for STI. PACS were used as the criterion standard.

Results: One-hundred sixty-two subjects were enrolled from July 2006 to July 2007 (mean [±SD] age = 32 [±10] years). Eighty-one percent of patients had a genitourinary symptom (most common: vaginal bleeding/spotting). SAVS had a sensitivity of 91% (95% CI = 60% to 99%), specificity of 99% (95% CI = 95% to 99%), positive likelihood ratio of 91, and negative likelihood ratio of 0.09 in diagnosing STIs. None of the patients reported difficulty or discomfort using this technique.

Conclusions: Self-administered vaginal swabs can be utilized as a feasible alternative to PACS for STI screening in the ED.

18. Adverse Drug Events Associated With the Antidotes for Methanol and Ethylene Glycol Poisoning: A Comparison of Ethanol and Fomepizole

Lepik KJ, et al. Ann Emerg Med. 2009;53:439-450.e10.

Study objective
We investigate adverse drug events associated with antidotes ethanol and fomepizole in methanol or ethylene glycol poisonings. An “adverse drug event” is harm associated with normal or incorrect drug use. We describe type, frequency, severity, seriousness, and onset time of adverse drug events and test the hypothesis that fomepizole results in fewer adverse drug events than ethanol.

This cohort study included patients aged 13 years or older, hospitalized between 1996 and 2005 for methanol or ethylene glycol poisoning (identified by International Classification of Diseases, Ninth Revision or 10th Revision codes) and treated with at least 1 dose of ethanol or fomepizole. Two abstractors separately reviewed each chart, identifying new clinical events during antidote treatment. Three toxicologists determined, by consensus, which events were adverse drug events. The primary outcome was at least 1 adverse drug event, expressed as adverse drug event rate per person-day of antidote treatment. Association between time to first adverse drug event and antidote type was modeled by Cox regression, adjusted for confounders.

Two hundred twenty-three charts were reviewed and 172 analyzed. Toxicologists identified at least 1 adverse drug event in 74 of 130 (57%) ethanol-treated and 5 of 42 (12%) fomepizole-treated cases. Central nervous system symptoms accounted for most adverse drug events (48% ethanol-treated, 2% fomepizole-treated). Severe adverse drug events occurred in 26 of 130 (20%) ethanol-treated (coma, extreme agitation, cardiovascular) and 2 of 42 (5%) fomepizole-treated (coma, cardiovascular). Serious (life-threatening) adverse drug events occurred in 11 of 130 (8%) ethanol-treated (respiratory depression, hypotension) and 1 of 42 (2%) fomepizole-treated (hypotension, bradycardia) cases. Median adverse drug event onset was within 3 hours after the start of either antidote. Ethanol and fomepizole adverse drug event rates were 0.93 and 0.13 adverse drug events per treatment-day, respectively. Adjusted hazard ratio was 0.16 (95% confidence interval 0.06, 0.40).

Given observational study limitations, results suggest lower occurrence of adverse drug events with fomepizole than ethanol.

19. Validation of a Universal Rule for Termination of Resuscitation in the Field

No survivors would have been missed if the rule had been applied to this study’s large sample of out-of-hospital cardiac arrest cases with presumed cardiac etiology.

Morrisonabd LJ, et al. Resus 2009;80:324-328.

Prehospital termination of resuscitation rules have been derived for Emergency Medical Technician-Paramedics providing advanced life support care and defibrillation-only Emergency Medical Technicians providing basic life support care. We sought to externally validate each rule on a prospective cohort of prehospital cardiac arrest patients to determine if either rule could be proposed as a universal prehospital termination of resuscitation rule.

Investigators at the University of Toronto performed a secondary cohort analysis of data prospectively collected for the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest trial from 1 April 2006 to 1 April 2007 by one site. The diagnostic test characteristics and predicted transportation rate were calculated for each rule.

Of the 2415 patients with cardiac arrest of presumed cardiac etiology, the advanced life support rule recommended termination of resuscitation for 743 patients. No survivors were identified in this group. It had a specificity of 100% for recommending transport of potential survivors, a positive predictive value of 100% for death and a predicted transport rate of 69%. The basic life support rule recommended termination of resuscitation for 1302 patients, with no survivors. This rule had a specificity of 100%, a positive predictive value of 100% and a predicted transport rate of 46%.

Implementing the basic life support rule as a universal termination of resuscitation clinical prediction rule would result in a lower overall transport rate without missing any potential survivors. The universal rule would recommend termination of resuscitation when there was no return of spontaneous circulation prior to transport, no shock was given and the arrest was not witnessed by Emergency Medical Services personnel. This rule may be useful for emergency medical services systems with mixed levels of providers responding to cardiac arrest patients.

20. Patient Comprehension of ED Care and Instructions: Are Patients Aware of When They Do Not Understand?

Engel KG, et al. Ann Emerg Med. 2009;53:454-461.e15.

Study objective
To be able to adhere to discharge instructions after a visit to the emergency department (ED), patients should understand both the care that they received and their discharge instructions. The objective of this study is to assess, at discharge, patients' comprehension of their ED care and instructions and their awareness of deficiencies in their comprehension.

We conducted structured interviews of 140 adult English-speaking patients or their primary caregivers after ED discharge in 2 health systems. Participants rated their subjective understanding of 4 domains: (1) diagnosis and cause; (2) ED care; (3) post-ED care, and (4) return instructions. We assessed patient comprehension as the degree of agreement (concordance) between patients' recall of each of these domains and information obtained from chart review. Two authors scored each case independently and discussed discrepancies before providing a final concordance rating (no concordance, minimal concordance, partial concordance, near concordance, complete concordance).

Seventy-eight percent of patients demonstrated deficient comprehension (less than complete concordance) in at least 1 domain; 51% of patients, in 2 or more domains. Greater than a third of these deficiencies (34%) involved patients' understanding of post-ED care, whereas only 15% were for diagnosis and cause. The majority of patients with comprehension deficits failed to perceive them. Patients perceived difficulty with comprehension only 20% of the time when they demonstrated deficient comprehension.

Many patients do not understand their ED care or their discharge instructions. Moreover, most patients appear to be unaware of their lack of understanding and report inappropriate confidence in their comprehension and recall.

21. Hazards of unintentional injection of epinephrine from autoinjectors: a systematic review

Simons FE, et al. Ann Allergy Asthma Immunol. 2009;102:282-287.

Objectives: To ascertain the rate of occurrence of unintentional injections from epinephrine autoinjectors used in the first aid treatment of anaphylaxis and to provide information about the resulting needle stick injuries.

Data Sources: A systematic review was performed. The MEDLINE, Scirus, CINAHL, ISI Web of Science, and Google Scholar databases were searched by title and abstract to identify reports of unintentional injections from epinephrine autoinjectors published in peer-reviewed journals.

Study Selection: Publications were selected for inclusion based on predefined strict criteria.

Results: In 26 reports published during the past 20 years, we identified 69 people with an unintentional injection of epinephrine from an autoinjector. More than 68% of them were reported in the past 6.3 years, 58% were female, 42% were injured in the home, and 91% sustained injury to a finger or thumb. More than 65% of the 69 individuals were evaluated in an emergency department; 13% of the 69 were not treated or were treated only with observation. Warming of the injured part was used in 25%, nitroglycerin paste application in 9%, local injections of phentolamine and/or lidocaine in 22%, and other treatments in 20%; treatment, or lack thereof, was not described in 12%. No permanent sequelae were reported.

Conclusions: The true rate of occurrence of unintentional injection of epinephrine from autoinjectors is unknown but is increasing. People at risk for anaphylaxis need regular coaching in how to use epinephrine autoinjectors correctly and safely. Improved autoinjector design will address the safety concerns identified in this review.